Confidential Client Information
Name (First & Last):
Email:
How often do you check email?*:
Street Address:
City:
State:
Province:
Region:
ZIP Code:
Phone (day):
Phone (cell):
Phone (night):
Who Referred You To Our Company:
Statistics
Age
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Birth Date
Gender
Select Gender
Male
Female
Height (in feet)
Blood Type*
Birth Weight (if known)
Current Weight
Ideal Weight
Weight One Year Ago
Would you like your weight to be different?
Family/Living Situation
How many people live in your home?
Children and Their Ages
Occupation
History
Have you lived or traveled outside of the United States? If so, when and where?
Have you or your family recently experienced any major life changes? If so, please comment:
Have you experienced any major losses in life? If so, please comment:
How much time have you had to take off from work or school in the last year?
0 to 2 days
3 to 14 days
More than 15 days
Did you experience any childhood trauma (emotional, physical, family/divorce) or serious health concerns?
Health
What are your health goals?
Goals
Please list any/all concerns about your health, eating habits, fitness, and/or body, rating them in matters of importance.
Please explain why the top 3 are the most important.
What do you expect from your coach?
Health Concerns
Please list any injuries, surgeries, or illnesses that you have had in the past.
Surgery/Illness/Injury
Date:
Years:
Please list any medications and/or supplements that you are currently taking.
Medication
Reason
What are your main health concerns? (Describe in detail, including the severity of the symptoms):
When did you first experience these concerns?
How have you dealt with these concerns in the past?
Have you experienced any success with these approaches?
What other health practitioners are you currently seeing? List name, specialty, and phone # below:
Please list the date and description of any surgical procedures you have had:
How often did you take antibiotics in infancy/childhood?
How often have you taken antibiotics as a teen?
How often have you taken antibiotics as an adult?
List any medicine you are currently taking:
List all vitamins, minerals, herbs, and nutritional supplements you are now taking:
Please list any supplements that you are currently taking:
Supplements
Reason
Have any other family members had similar problems (describe)?
Nutritional Status
Are there any foods you avoid because of how they make you feel? If yes, please name the food and the symptom:
Do you have symptoms immediately after eating, like bloating, gas, sneezing, or hives? If so, please explain:
Are you aware of any delayed symptoms after eating certain foods, such as fatigue, muscle aches, sinus congestion, etc? If so, please explain:
Are there foods that you crave? If so, please explain:
Describe your diet at the onset of your health concerns:
Do you have any known food allergies or sensitivities?
What percentage of your meals are home-cooked?
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Is there anything else I should know about your current diet, history, or relationship to food?
Change
If so, what? (please specify which ones worked well for you)
How specifically would you like this to be different?
If you were to consider making changes to these habits, health choices and your body, what might come to mind?
Until now, what has been the biggest barrier to making these changes?
What does your fitness program consist of currently?
Intestinal Status
Do you experience intestinal gas? If so, please explain if it is excessive, occasional, odorous, etc:
Have you ever had food poisoning? If yes, please describe in detail, including 1) Where were you 2) What did you treat it with and 3) If you feel like you fully recovered from it:
Medical Status
Briefly describe your symptoms, chosen treatment(s), and dates for the above list:
Relationships
Finances
Career
Lifestyle History
Have you had periods of eating junk food, binge eating or dieting? List any known diet that you have been on for a significant amount of time.
Have you used or abused alcohol, drugs, meds, tobacco or caffeine? Do you still?
How do you handle stress?
Sleep History
Are you satisfied with your sleep?
Do you stay awake all day without dozing?
Are you asleep (or trying to sleep) between 2:00 a.m. and 4:00 a.m.?
Do you fall asleep in less than 30 minutes?
Do you sleep between 6 and 8 hours per night?
Mental Health Status
How are your moods in general? Do you experience more anxiety, depression, or anger than you would like?
On a scale of 1-10, one being the worst and 10 being the best, describe your usual level of energy.
At what point in your life did you feel best? Why?
Other
Do you think family and friends will be supportive of you making health and lifestyle changes to improve your quality of life? Explain, if no.
Who in your family or on your health care team will be most supportive of you making dietary changes?
Please describe any other information you think would be useful in helping to address your health concern(s):
What are your health goals and aspirations?
Though it may seem odd, please consider why you might want to achieve that for yourself:
Forms Of Relaxation
What kind of relaxation techniques do you use? Are breathing, meditation, journaling, yoga, etc. involved?
What role do sports and exercise play in your life?
Coaching, Consulting, Or Additional Services
How did you hear about us?
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Our Terms And Conditions
Your health and well-being are interconnected with your nutrition and lifestyle. By submitting this form, you acknowledge that the information provided is accurate and that any treatment or recommendations are based on the data you've provided. Any health issues resulting from inadequate or inaccurate information are your responsibility.
One's health and well-being are directly influenced by their nutrition and vice versa. By completing this form, you accept that all mentioned information is correct and that you are accepting a treatment that is prepared based on the provided data. Any health condition occurred by a lack of information that is triggered due to the provided diet will be on customers' responsibility.
Client Signature:
Date:
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